I am deciding which type of reconstruction to have and am wondering why you must have tissue expanders when women having a simple breast enlargement can go from an A to a DD straight away? They must not have that much skin either, having only small breasts to start with. I have an appointment in a week to discuss my options with a surgeon.
Why Tissue Expanders? Having Bilateral, Skin Saving Mastectomy With Immediate Reconstruction?
Doctor Answers (4)
Options for breast reconstruction
A direct to implant with alloderm is possible for skin sparing mastectomies, but some surgeons will place tissue expanders if they do not feel the skin envelope is big enough. Remember the skin now is compromised and trying to stretch it out without a lot of soft tissue underneath it may cause skin necrosis.
Straight to implant reconstruction a less desirable choice in most instances
Direct to implant reconstruction is very difficult to pull off successfully as there are many variables that can affect it's success. Most of us who do high volume breast cancer surgery attempt it at some point and switch back to the traditional 2 stage method I would say. The predictability of the result of a 2 stage surgery with implants following expanders cannot be matched in most instances. Going straight to a full volume implant adds unnecessary risk to the mastectomy perfusion, particularly with some of the nipple sparing incisions we use.
Conceptually, the skin will retract/contract to some degree following mastectomy. The greater stability and rigidity of an expander provide a better platform to control the shape during this process. Also, the use of an ADM like Alloderm frequently results in fluid collections or seromas which have to be aspirated which is difficult to do with a permanent device over fear of puncture of the implant.
If one wishes to attempt a straight to implant reconstruction, the post -operative adjustable saline device from Mentor (the "spectrum" model) is the most logical as it can serve as a poor man's tissue expander when needed.
Immediate breast Reconstruction
In immediate breast reconstruction, the general surgeon will do the mastectomy , if it is skin sparing mastectomy, then the general surgeon will take out the nipple areola and varying amount of skin. Also the skin thickness left behind varies with the general surgeons degree of comfort. So the tissue expander is to regain the amount taken by the general surgeon otherwise you will be flat at the level of the nipple areola. Also one needs to consider the thickness and vascularity of the flaps of skin, if the implant is large enough it may put pressure on the skin and cause the skin to die (Skin Necrosis). You can do an Immediate Latismus Dorsi flap that will give good coverage for the implant and new blood supply to the area. You aothe options in breast reconstruction is TRAM flap, and then micro-vascular flaps
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When to consider "direct-to-implant" reconstruction
The option of direct-to-implant reconstruction is becoming more common in conjunction with skin-sparing mastectomy. Several factors are required in order for this to work: First, the skin flaps after the mastectomy have to have excellent blood flow; mastectomy surgeons sometimes make the flaps thin for more aggressive tissue removal, and this would place the reconstruction at risk. Tissue expansion allows for some healing time before putting pressure on the skin. Second, an acellular dermal matrix such as Alloderm is used (this would also be used with tissue expansion). Third, no plans for radiation treatment or chemotherapy.
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